Provider Demographics
NPI:1720126535
Name:TZANETAKOS, NICHOLAS GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:GEORGE
Last Name:TZANETAKOS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1256 WATERFORD DRIVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504
Mailing Address - Country:US
Mailing Address - Phone:630-499-2404
Mailing Address - Fax:630-499-2399
Practice Address - Street 1:99 BOULDER HILL PASS
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:IL
Practice Address - Zip Code:60538
Practice Address - Country:US
Practice Address - Phone:630-897-2848
Practice Address - Fax:630-897-4498
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2017-07-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036066510207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036066510Medicaid
IL036066510Medicaid
IL772570Medicare PIN